Natural History of Small Gastric Subepithelial Lesions Less than 20 mm: A Multicenter Retrospective Observational Study (NUTSHELL20 Study)

BACKGROUND AND AIM

Small gastric subepithelial lesions (SELs) are sometimes encountered in daily esophagogastroduodenoscopy (EGD) practice, but whether once-annual or twice-annual endoscopy can provide sufficient follow-up remains unclear. Because follow-up based on small-SEL characteristics is important, this study clarified the natural history of gastric SELs less than 20 mm.

METHODS

This retrospective multicenter observation study conducted at 24 Japanese hospitals during April 2000 to March 2020 examined small gastric SELs of ≤20 mm diameter. The primary outcome was the rate of size increase of those SELs detected using EGD, with growth times assessed irrespective of SEL pathological diagnoses.

RESULTS

We examined 824 cases with tumors of 1-5 mm diameter in 298 (36.2%) cases, 6-10 mm in 344 (41.7%) cases, 11-15 mm in 112 (13.6%) cases, and 16-20 mm in 70 (8.50%) cases. An increase of small gastric SELs was observed in 70/824 patients (8.5%). The SELs larger than 6 mm increased, even after 10 years. No-change and increasing groups had no significantly different malignant findings at diagnosis. In cases of gastrointestinal stromal tumors (GISTs), internal cystic change in endoscopic ultrasound (EUS) is a risk factor for an increased tumor size. The predictive tumor growth cutoff size at initial diagnosis was 13.5 mm.

CONCLUSIONS

Small gastric SELs less than 20 mm have an approximately 8.5% chance of increase. Predictive markers for GIST growth are tumor size ≥13.5 mm and internal cystic change in EUS.

The post-operative changes in the level of inflammatory markers after posterior lumbar interbody fusion

Inflammatory markers such as the C-reactive protein (CRP), white blood cell count and body temperature are easy to measure and are used as indicators of infection. The way in which they change in the early post-operative period after instrumented spinal surgery has not been reported in any depth.

We measured these markers pre-operatively and at one, four, seven and 14 days postoperatively in 143 patients who had undergone an instrumented posterior lumbar interbody fusion.

The CRP proved to be the only sensitive marker and had returned to its normal level in 48% of patients after 14 days. The CRP on day 7 was never higher than that on day 4. Age, gender, body temperature, operating time and blood loss were not related to the CRP level. A high CRP does not in itself suggest infection, but any increase after four days may presage infection.

Gastric longitudinal shortening may occur during gastric phase III activities in man

BACKGROUND AND AIM

The aim of this study was to determine whether the gastric longitudinal shortening occurs during the gastric phase III in man.

METHODS

Intragastric pH and gastroduodenal motility were simultaneously measured by means of a 24-h ambulatory recording system in 14 healthy volunteers. In nine subjects (group A), the catheter assembly was endoscopically clipped to the gastric mucosa with the middle transducer and the distal pH sensor in the antrum. In the remaining five subjects (group B), measurements were performed without securing the assembly.

RESULTS

In 23 of the 25 gastrointestinal interdigestive migrating complexes in group A, the distal and middle transducers showed characteristic duodenal contractions (11-12 c.p.m.). Neutralization was noted at the distal pH sensor. Similar phenomena were observed during all 15 gastrointestinal interdigestive migrating complexes in group B. The catheter assemblies escaped into the duodenum despite the fact that they were secured to the stomach. This may be explained by gastric longitudinal shortening during gastric phase III activities.

CONCLUSIONS

Studies of intragastric physiology with test catheters must take the effect of gastric longitudinal shortening during phase III into consideration.

Diagnosis of gastroesophageal reflux disease using a new questionnaire

BACKGROUND AND AIM

An early and accurate evaluation by a general practitioner is needed to screen out non-gastroesophageal reflux disease (GERD) patients. A recent questionnaire (QUEST) highlighted problems with specificity and complexity, so the aim of the present study was to design a simplified questionnaire.

METHODS

When admitted to hospital to undergo an upper gastrointestinal endoscopy for suspected GERD, 333 patients completed a 50-item questionnaire requiring 'yes/no' answers to different combinations of questions relating to symptoms of upper gastrointestinal tract conditions (e.g. GERD, ulcers and functional dyspepsia) and psychosomatic symptoms. The endoscopic diagnosis was then correlated with the rate of positive answers to each question.

RESULTS

Based on the analysis of the 50 items, the 8-10 questions most often answered affirmatively by each of the GERD and non-GERD groups were chosen for the simplified questionnaire. Three draft questionnaires were compiled. After calculating the sensitivity, specificity and accuracy in relation to the diagnosis of GERD and other conditions, it was found that questionnaire B (selection of persons answering 'yes' to at least one of questions 1-5 and exclusion of persons answering 'yes' to at least three of questions 7-10) had a high sensitivity, high specificity and low false positive rate.

CONCLUSION

A novel questionnaire was developed. It was designed to detect the symptoms of GERD while simultaneously excluding non-GERD patients. This simplified nine-item simplified questionnaire had a sensitivity of 79.8%, a specificity of 53.6% and an accuracy of 63.4%.

Development and evaluation of FSSG: frequency scale for the symptoms of GERD

BACKGROUND

The aim of this study was to produce a simplified questionnaire for evaluation of the symptoms of gastroesophageal reflux disease (GERD).

METHODS

A total of 124 patients with an endoscopic diagnosis of GERD completed a 50-part questionnaire, requiring only "yes" or "no" answers, that covered various symptoms related to the upper gastrointestinal tract, as well as psychosomatic symptoms. The 12 questions to which patients most often answered "yes" were selected, and were assigned scores (never = 0; occasionally = 1; sometimes = 2; often = 3; and always = 4) to produce a frequency scale for symptoms of GERD (FSSG). Sensitivity, specificity, and accuracy of the FSSG questionnaire were evaluated in another group of patients with GERD and non-GERD. The usefulness of this questionnaire was evaluated in 26 other GERD patients who were treated with proton pump inhibitors for 8 weeks.

RESULTS

When the cutoff score was set at 8 points, the FSSG showed a sensitivity of 62%, a specificity of 59%, and an accuracy of 60%, whereas a cutoff score of 10 points altered these values to 55%, 69%, and 63%. The score obtained using the questionnaire correlated well with the extent of endoscopic improvement in patients with mild or severe GERD.

CONCLUSIONS

This new questionnaire is useful for the objective evaluation of symptoms in GERD patients.

Alkaline esophagitis evaluated by endoscopic ultrasound

CASE REPORT

Two patients with corrosive esophagitis caused by alkaline household agents were examined with endoscopic ultrasound using a 20-MHz probe. In the first case, endoscopic ultrasound revealed circumferentially thickened mucosa and muscularis propria, and lack of differentiation between the mucosa and submucosa. However, esophageal stricture did not develop during 3 months of follow-up, suggesting that the deep lesion may have involved a narrow section of esophagus only. In the second case, a markedly thickened mucosa was seen, resulting in no sequelae. Endoscopic ultrasound offers a more accurate evaluation of the depth of the lesions in alkaline esophagitis compared to standard endoscopy or computed tomography. Longitudinal studies are needed to identify lesions at greatest risk for progression to stricture.

Effect of neutral endopeptidase inhibitor on bradykinin-induced bronchoconstriction

To evaluate whether neutral endopeptidase (NEP) inhibitors have adverse respiratory effects, the influence of a NEP inhibitor on bradykinin (BK)-induced bronchoconstriction was investigated. In anesthetized and artificially ventilated guinea pigs, changes in airway opening pressure (Pao) were measured as an index of bronchoconstriction. An infusion of phosphoramidon (3 mg kg(-1) h(-1)), a NEP inhibitor, significantly enhanced the bronchoconstriction induced by high-dose BK (30 nmol kg(-1), i.v.). Capsaicin (0.1 mg kg(-1), i.v.) and SR48968 (0.3 mg kg(-1), i.v.), an NK2 receptor antagonist, significantly inhibited the phosphoramidon-induced enhancement of BK-induced bronchoconstriction, although FK888 (3 mg kg(-1), i.v.), an NK1 receptor antagonist, did not. Both neurokinin A (NKA) (0.1-3 nmol kg(-1), i.v.) and substance P (SP) (0.1-3 nmol kg(-1), i.v.) induced dose-dependent bronchoconstriction which was enhanced by phosphoramidon infusion, although these enhancements were more prominent in the NKA series. Phosphoramidon partially inhibited BK degradation in lung homogenate, and both NKA and SP degradation in the lung homogenate were significantly suppressed by phosphoramidon. In bronchoalveolar lavage fluid (BALF), levels of NKA and SP were significantly elevated after a bolus of BK with a phosphoramidon infusion. These results suggest that NEP inhibitors may have adverse respiratory effects resulting from inhibition of the degradation of neurokinins, but mainly of NKA, when a large amount of BK is generated.

Anchoring and bola cationic amphiphiles for nucleotide delivery. Effects of orientation and extension of hydrophobic regions

Novel cationic amphiphiles, based on lithocholic acid derivatives with two structural motifs, anchoring lipids and bola lipids, were designed and synthesized. Both bear extended hydrophobic space-filling substituents. A significant effect of the orientation and extension of hydrophobic regions around the ether linkage at the 3-position was found on the efficiency of DNA delivery.

Tight Sylvian cisterns associated with hyperdense areas mimicking subarachnoid hemorrhage on computed tomography--four case reports

Four patients with supratentorial mass lesions (two chronic subdural hematomas, one acute epidural hematoma, and one acute subdural hematoma) showed hyperdense sylvian cisterns on computed tomography (CT). Association of subarachnoid hemorrhage was suspected initially, but was excluded by intraoperative observation or postoperative lumbar puncture. CT showed disappearance of the hyperdense areas just after evacuation of the mass lesions. The hyperdense areas are probably a result of the partial volume phenomenon or concentrations of calcium deposits rather than abnormally high hematocrit levels, which were not found in these patients.

Traumatic basilar artery occlusion caused by a fracture of the clivus--case report

A 56-year-old man presented with a rare traumatic basilar artery occlusion caused by a fracture of the clivus. He fell from the height of 2 meters and immediately fell into a coma. Head computed tomography (CT) revealed an open depressed fracture, an acute epidural hematoma 1 cm thick in the left middle frontal fossa, and a longitudinal fracture of the clivus. Emergency removal of the hematoma was performed with cranioplasty. Head CT 8 hours 50 minutes after injury showed infarctions in the brain stem, cerebellum, and occipital lobes. Cerebral angiography revealed occlusion of the basilar artery in the middle part of the clivus. The patient died after 3 days. Autopsy revealed that the basilar artery was trapped in the clivus fracture site. Vertebrobasilar artery occlusion due to trapping in a clivus fracture has a very poor prognosis. Diagnosis is difficult and generally only confirmed at autopsy. Cerebral angiography is recommended in a patient in a deep coma without massive brain contusion at the early stage of head injury to identify the possibility of vertebrobasilar artery occlusion in a clivus fracture.

Structural features of aliphatic N-nitrosamines of 7-azabicyclo[2.2.1]heptanes that facilitate N-NO bond cleavage

N-Nitrosamines can be considered as potential nitric oxide (NO)/nitrosonium ion (NO(+)) donors. However, the relation of the structures of N-nitrosamines, in particular of aliphatic N-nitrosamines, to the characteristics of release of NO or NO(+) remains unclear. Here we show that aliphatic N-nitrosoamines of 7-azabicyclo[2.2.1]heptanes can undergo heterolytic N-NO bond cleavage. On the basis of the observation of reduced rotational barriers of the N-NO bonds in solution and nitrogen-pyramidal structures of the N-nitroso group in the solid state, we postulate that N-NO bond cleavage of N-nitrosamines is enhanced by a reduction of the resonance in the N-NO group. Computational studies suggest that these structural features of the N-nitrosamines of 7-azabicyclo[2.2.1]heptane are derived from angle strain imposed on the CNC angles.

Acute mercuric chloride poisoning: effect of co-ingested milk on outcome and continued hyperamylasemia

Thirty-six h after intentionally ingesting 25 g of mercuric chloride powder mixed with 5O mL of milk, an elderly woman presented to the emergency department with diffuse upper gastrointestinal erosions and acute renal failure. The patient was treated with dimercaprol and hemodialysis, and was discharged from the hospital without clinically apparent sequelae. However, elevated serum concentrations of amylase and proteases persisted for several months despite normal findings by computed tomography including contrast administration. Delayed absorption and weakened corrosive effect may have resulted from the binding of mercuric chloride to thiol-containing proteins in milk, improving the clinical outcome.

Usefulness and limitation of DiBAC4(3), a voltage-sensitive fluorescent dye, for the measurement of membrane potentials regulated by recombinant large conductance Ca2+-activated K+ channels in HEK293 cells

The usefulness of bis-(1,3-dibutylbarbituric acid)-trimethine oxonol (DiBAC4(3)), a voltage-sensitive fluorescent dye, for the measurement of membrane potentials (MPs) was evaluated in HEK293 cells, where alpha or alpha plus beta1 subunits of large conductance Ca2+-activated K+ (BK) channels were expressed (HEKBK alpha and HEKBK alphabeta). The fluorescent intensity of DiBAC4(3) was measured at various potentials under voltage-clamp for calibration to estimate the absolute MP semi-quantitatively. The resting MPs measured with DiBAC4(3) were roughly comparable to those recorded with a microelectrode; the MP in HEKBK alphabeta was 10-20 mV more negative than that in native HEK. In HEKBK alpha, the membrane hyperpolarization induced by 10 microM Evans blue, a BK channel opener, was detected with DiBAC4(3). NS-1619, another BK channel opener, induced gradual but substantial change in F/F(K) even in native HEK, while the BK channel opening effect was detected. Oscillatory membrane hyperpolarization was induced in HEKBK alphabeta by application of 10 microM acetylcholine via increase in intracellular Ca2+ concentration. The oscillatory hyperpolarization was, however, detected only as a slow hyperpolarization with DiBAC4(3). It can be concluded that relatively slow effects of BK channel modulators can be semi-quantitatively measured by use of DiBAC4(3) in HEKBK, while the limited temporal resolution and possible artifacts should be taken into account.

Midazolam for continuous sedation in Japanese patients in the critical care setting: phase II study

This prospective, phase II study was carried out to evaluate the efficacy and safety of midazolam as a sedative agent in nine critically ill Japanese patients without coma who had been admitted to an intensive care unit. An adequate level of sedation (sedative score [SS] 4-6) was induced by midazolam 0.14 - 0.39 mg/kg and maintained with a dose range of 0.08 - 0.24 mg/kg per h. One patient was excluded from the efficacy analysis since optimum sedation was not maintained by continuous infusion. The percentage of time during which SS 5 was achieved varied among the patients. The most frequent adverse events were hypotension, partial pressure of carbon dioxide elevation and premature ventricular contraction. Population pharmacokinetic analysis suggested that lower drug clearance rates were correlated with the presence of complications. The 50% of effective concentration values of SS 5, estimated by logistic regression analysis, varied greatly (mean, 251 ng/ml). In conclusion, midazolam infusion achieved successful sedation in this critical care setting. The optimum dose differed among the patients, however, and was influenced by the presence of complications.

Mutation spectrum of o-aminoazotoluene in the cII gene of lambda/lacZ transgenic mice (MutaMouse)

The o-aminoazotoluene (AAT) has been evaluated as a possible human carcinogen by the International Agency for Research on Cancer. In rodents, it is carcinogenic mainly in the liver, and also in lung following long term administration. We previously examined in lambda/lacZ transgenic mice for the induction of lacZ mutations in liver, lung, urinary bladder, colon, kidney, bone marrow, and testis. AAT induced gene mutations strongly in the liver and colon. In the present report, we reveal the molecular nature of mutations induced by AAT in the lambda cII gene (the cII gene, a phenotypically selectable marker in the lambda transgene, has 294bp, which makes it easier to sequence than the original target, the 3kb lacZ gene). The cII mutant frequency in liver and colon was five and nine times higher, respectively, in AAT-treated mice than in control mice. Sequence analysis revealed that AAT induced G:C to T:A transversions, whereas spontaneous mutations consisted primarily of G:C to A:T transitions at CpG sites.

Partial characterization of genes whose transcripts accumulate preferentially in cell clusters at the earliest stage of carrot somatic embryogenesis

We attempted to identify genes that are preferentially expressed immediately after somatic cells divide to form cell clusters at the earliest stage of carrot somatic embryogenesis when they are not or barely expressed in non-embryogenic suspension-cultured cells in the presence of 2,4-D. Using the differential display technique, we isolated three cDNA clones, designated No. 43, No. 87 and No. 93. The No. 43 transcript was preferentially expressed in the earliest cell clusters, its level decreased drastically at the globular and heart-shaped and torpedo-shaped stages, and it was not detected in non-embryogenic suspension-cultured cells. No. 43 cDNA encoded a protein with homology to thaumatin-like proteins and the deduced positions of seven cysteine residues in the 63 amino acid sequence from the carboxyl terminus were identical to those in thaumatin-like proteins. The full-length nucleotide sequence of No. 93 cDNA was determined and its product was about 80% homologous to precursor of the 14 kDa proline-rich DC 2.15 protein of carrot at the amino acid level. However, the deduced amino acid sequence lacked the characteristic core of repeating Pro-X motifs found in DC 2.15. The No. 93 transcript accumulated preferentially in the earliest cell clusters but it was also detected at a low level in non-embryogenic suspension-cultured cells, unlike DC 2.15 transcripts that begin to accumulate in heart-shaped embryos before their level falls in torpedo-shaped embryos. No. 87 transcripts were expressed preferentially in the earliest cell clusters that has been incubated with 2,4-D but were also detected at a low level in suspension-cultured cells subcultured in the continued presence of 2,4-D. The No. 87 cDNA exhibited no significant homology to any sequences in databases.

Space-filling effects in membrane disruption by cationic amphiphiles

We studied the hemolytic activity towards bovine erythrocytes of novel synthetic steroid-polyamine conjugates consisting of a rigid hydrophobic steroid unit, and a flexible hydrophilic polyamine unit connected by a linker. The steroid structure, polyamine chain length, and the presence of a hydrophobic substituent on the steroid, all influenced the activity. Analysis of the time dependence of hemolysis suggested that these structurally related cationic amphiphiles have different mechanisms of membrane perturbation.

Reanalysis of unruptured intracranial aneurysm management: effect of a new international study on the threshold probabilities

OBJECTIVE

This report updates previous clinical decision analysis for patients with unruptured intracranial aneurysm (UN-AN) based on newly published data and discusses the role of reanalysis in individual decision making.

METHODS

The authors employed probabilities for the natural history of UN-AN and results of preventive surgery based on the report by the International Study of Unruptured Intracranial Aneurysms. Probabilistic sensitivity analysis with Monte Carlo simulation and traditional n-way sensitivity analyses were used to assess the uncertainty of clinical decisions.

RESULTS

The baseline decision in favor of preventive surgery is reversed by new data from the international study. Probabilistic sensitivity analyses revealed several populations showing heterogeneity in terms of strategy selection. One- and two-way sensitivity analyses detected two important factors for decision making: annual rupture rate and utility for knowingly living with UN-AN.

CONCLUSIONS

Annual UN-AN rupture rate and the utility for knowingly living with UN-AN are key factors when deciding on a therapeutic strategy. Also, updating published decision analyses can improve clinical decision making by integrating clinical judgment and newly available clinical data.

Case report: right subclavian artery pseudoaneurysm due to perforation of esophageal cancer

A 51-year-old man presented with massive hematemesis. Perforation of upper esophageal cancer, which had already occurred at least six days earlier, progressed to upper mediastinitis. The mediastinitis contiguous to the right subclavian artery was considered to have caused a pseudoaneurysm. Rupture of the pseudoaneurysm into the esophagus resulted in massive hematemesis. Both enhanced computed tomography and angiography were diagnostic for the pseudoaneurysm. Transluminal endovascular stent-grafts placement was successful in preventing subsequent hemorrhage.

Gluteal muscle necrosis following transcatheter angiographic embolisation for retroperitoneal haemorrhage associated with pelvic fracture

Transcatheter angiographic emobilisation has been used as an effective control of haemorrhage associated with pelvic fracture. Although few complications of this procedure have been reported, gluteal muscle necrosis occurs occasionally. We assessed the type of pelvic fracture, concomitant injury, embolic site, embolic materials, and outcome in cases of gluteal muscle necrosis associated with angiographic embolisation for pelvic fracture-related haemorrhage, and investigated the factors associated with the development of gluteal muscle necrosis, one of the fatal complications of transcatheter angiographic embolisation. Five out of the 151 patients (incidence, 3.3%) who underwent transcatheter angiographic embolisation for haemorrhagic shock due to pelvic fracture developed gluteal muscle necrosis after embolisation. The five cases had injury severity scores ranging from 26 to 59 (mean 46.4). Three patients died (mortality, 60%) of subsequent sepsis and disseminated intravascular coagulation. These cases showed that transcatheter angiographic embolisation with gelatin sponge and/or steel coil, while effectively controlling bleeding, may also result in gluteal muscle necrosis. Aggressive management including intraarterial antibiotic treatment may have a role, but our numbers are too small to confirm this.

[Nitrogen pyramidal amides and related compounds]

A planar amide bond is a fundamental linkage in the structures of peptides and proteins. The rigid planarity of the amide linkage, due to a conjugation between carbonyl and amine groups, may be requisite for encoded protein folding and many other biological processes. Non-planar amides in the ground state will decode the significance of the planarity and rigidity of the amide linkage. We show here that simple amides of 7-azabicyclo[2.2.1]heptane, free from steric bias, including parent N-benzoyl 7-azabicyclo[2.2.1]heptane, are nitrogen-pyramidal amides in the crystalline state. We can suggest that pyramidalized amide nitrogen is a general feature and intrinsic to the 7-azabicyclo[2.2.1]heptane motif. Low rotational barriers of the amide C-N bond in a series of N-benzoyl amides of 7-azabicyclo[2.2.1]heptane, compared to monocyclic amides, may imply that ground-state nitrogen pyramidalization of the former amides also exist in solution. The 7-azabicyclo[2.2.1]heptane motif also favors nitrogen pyramidalization of sulfonamides and N-nitrosoamines, which can lead to pharmacophores after appropriate modification.

[Clinical analysis of hypothermia in children with severe head injury]

Therapeutic hypothermia may improve outcome after severe head injury, but its efficacy has not been established in children with a severe head injury. The authors evaluated the effects of hypothemia (33-34 degrees C) in 9 severely closed head-injured children (under 16 years old). The cooling period was 3 to 21 days (mean 9.3). Hypothermia significantly reduced ICP when it reached 33-34 degrees C. From 3 to 6 months after injury, 6 (67%) of the 9 patients had good outcome (good recovery in 2 and moderate disability in 4), but 3 (33%) had poor outcome (severe disability in 2 and vegetative state in one). Complications, including infectious disorders (pneumonia, meningitis, sepsis), cardio-vascular system dysfunction (cardiac arrhythmia, hypotension), decreased platelet counts, hypokalemia, diabetes insipidus, acute pancreatitis occurred during hypothermia in 7 patients (78%). The results of this study suggest that treatment with hypothermia in children with severe head injury is often accompanied complications, but it is an effective method to control intracranial hypertension and may have improved the outcome.

Gene transfection activities of amphiphilic steroid-polyamine conjugates

The design and evaluation of a novel potent class of DNA delivery agents based on steroid-polyamine conjugates bearing a flexible linker are reported. The hydrophobic regions are based on steroids, i.e. chlolestane and lithocholic acid motifs. The linker, which couples a hydrophobic steroid and a hydrophilic polyamine, in this study can be regarded as a two-atom extension of the conventional carbamate linker. We found that the gene transfection activity of the steroid-polyamine conjugates is influenced by the polyamine chain length and steroid structure. Molecular modeling of the relevant amphiphilic molecules revealed low-energy structures in which the polyamine chains are folded rather than stretched. This work suggests a significant effect of space-filling, i.e. the shape and orientation of the hydrophilic and hydrophobic regions, upon the efficiency of gene transfection.

The effect of a hemofilter during extracorporeal circulation on hemodynamics in patients with SIRS

OBJECTIVE

To evaluate the hypothesis that extracorporeal hemopurification with a hemofilter contributes to the stabilization of hemodynamics in patients with systemic inflammatory response syndrome (SIRS) due to a mechanism other than the removal of cytokines.

DESIGN

Prospective study.

SETTING

Intensive care unit (ICU) in a university hospital.

PATIENTS

Seven critically ill patients who met criteria for SIRS with unstable hemodynamics requiring vasopressors after emergency surgery.

INTERVENTIONS

Before initiation of continuous hemofiltration (CHF) extracorporeal circulation through the hemofilter (ECC) with a hollow-fiber polyacrylonitrile hemofilter was performed for 6 h.

MEASUREMENTS AND RESULTS

Vital signs were monitored continuously and hemodynamics were evaluated intermittently. The blood level of endotoxin and the plasma levels of cytokines were measured at 0 and 6 h. Changes in plasma levels of cytokines passing through the hemofilter were evaluated at 3 h. A significant decrease of body temperature (P < 0.05 at 3 and 6 h vs 0 h), a significant elevation of mean arterial pressure (P < 0.05 at 0.5 h, P < 0.01 at 3 and 6 h vs 0 h), and a significant increase of urinary flow rate (P < 0.05 at 0 to 3 h vs -3 to 0 h) were observed with ECC. Neither the blood level of endotoxin nor the plasma levels of cytokines decreased. A significant increase of plasma IL-6 as it passed through the hemofilter was noted.

CONCLUSIONS

The beneficial effects of hemopurification with a hemofilter on SIRS patients are possibly due to mechanisms other than the elimination of cytokines with ultrafiltration, diffusion, or adsorption.

Urinary excretions of albumin and type IV collagen in normotensive and hypertensive subjects

Plasma albumin leaks into urine as a result of glomerular hypertension and basement membrane injury, while urinary type IV collagen derives from mesangial matrix and glomerular basement membrane. The purpose of this study was to elucidate the pathophysiological significance of these urinary microproteins as an indicator of cardiovascular organ injuries in hypertension. In health-checkup participants without diabetes, proteinuria, or microhematuria, and who were not being treated for hypertension or any other disease at the time of enrollment, urinary albumin and type IV collagen were measured and their relations to organ injuries and cardiovascular risk factors were evaluated. Of 1,079 subjects (40- to 65-year-old; 256 men and 823 women) enrolled in the study, 120 (11.1%) had untreated hypertension exceeding 140/90 mmHg. Urinary albumin was positively correlated with both age (r=0.16, p<0.001) and systolic blood pressure (r=0.27, p<0.001). Urinary type IV collagen was not only positively correlated with age (r=0.12, p<0.001) and diastolic blood pressure (r=0.14, p<0.001) but also negatively correlated with blood hemoglobin (r=-0.12, p<0.001). Urinary albumin, but not type IV collagen, had a significant relation to electrocardiographic signs of left ventricular hypertrophy (p=0.012) and retinal arteriosclerosis on fundoscopy (p <0.001). Thus both albumin and type IV collagen would seem to have increased in association with age and hypertension in this cohort. It is suggested that urinary albumin is an indicator not only of renal injury, but also possibly of development of cardiac hypertrophy and arteriosclerotic changes. Urinary type IV collagen, on the other hand, may be associated with renal tissue injuries that affect erythrokinetics.

Myocardial infarction with acute insulin poisoning--a case report

A 36-year-old woman without overt coronary risk factors was admitted to hospital with coma about 9 hours after mass self-injection of insulin (1,500 units). Laboratory investigation revealed severe hypoglycemia and hyperinsulinemia. During the treatment of her hypoglycemia, circulatory collapse occurred. The ECG, echocardiogram, and elevation in troponin T suggested a diagnosis of myocardial infarction. Although the patient became apallic and developed systemic spasticity due to hypoglycemic brain damage, her hemodynamics improved with supportive care alone. Coronary angiography and myocardial scintigraphy performed later demonstrated a broad area of myocardial damage despite intact coronary artery circulation. The authors hypothesize that temporary coronary arterial narrowing or coronary arterial vasospasm induced by severe hyperinsulinemia contributed to the pathogenesis of the myocardial infarction. The possibility of myocardial infarction should be considered in patients with acute insulin poisoning.

Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas

BACKGROUND

In the treatment of patients with pancreatic injury, the focus of attention is usually on main ductal injuries.

METHODS

To develop a classification system for pancreatic ductal injuries, we retrospectively analyzed blunt pancreatic injuries in 40 patients. We assessed the relationships between findings on pancreatography (36 endoscopic retrograde procedures and 4 transduodenal procedures), the treatment modality, and the clinical course.

RESULTS

Patients with class 1 injuries (radiographically normal ducts, n = 13) could be treated nonsurgically without major complications. Patients with class 2 injuries (branch injuries, n = 7), in whom contrast medium from ductal branches did not leak from the pancreatic parenchyma (class 2a, n = 3), could be treated nonsurgically. Patients with leaks into the retroperitoneal space (class 2b, n = 4) required at least a drainage laparotomy. Patients with class 3 injuries (main duct injuries, n = 20), including two patients in whom conservative treatment resulted in severe complications, required laparotomy.

CONCLUSION

This classification system for pancreatic ductal injuries may facilitate the selection of appropriate therapeutic modalities for patients with blunt pancreatic injury.

Pulse steroid therapy in adult respiratory distress syndrome following petroleum naphtha ingestion

CASE REPORT

A suicide attempt by a 23-year-old woman involved ingestion of 1000 mL of petroleum naphtha. Early chemical pneumonitis was complicated by life-threatening, diffuse interstitial lung consolidation with pneumatoceles. Pulse steroid therapy beginning on day 17 was associated with remarkable resolution of interstitial consolidation, although an enlarging secondarily infected pneumatocele ruptured to produce a bronchopleural fistula. Thoracic surgery and antibiotic therapy resulted in improvement of the patient's respiratory condition, and she was discharged with no residual respiratory symptoms. High-dose corticosteroid therapy appears to be a useful addition to aggressive supportive treatment in late adult respiratory distress syndrome following hydrocarbon ingestion.

A giant intramural gastric hematoma successfully treated by transcatheter arterial embolization

We describe a case of intramural gastric hematoma with hemorrhagic shock caused by the formation of a large hematoma. Computed tomographic and angiographic examinations confirmed the presence of active bleeding into the hematoma. Transcatheter arterial embolization (TAE) was performed for hemostasis. To our knowledge, although 21 cases of intramural gastric hematoma have been reported in the literature, this is apparently the first case treated by TAE. We conclude that TAE is a safe and effective treatment option for intramural gastric hematoma confirmed to be associated with active bleeding into the hematoma.

Cardiovascular response and stress reaction to flumazenil injection in patients under infusion with midazolam

OBJECTIVES

To evaluate the cardiovascular response and acute stress reaction after arousal induced by a benzodiazepine antagonist, flumazenil, in patients sedated with midazolam.

DESIGN

Prospective study.

SETTING

Emergency center in a university hospital.

PATIENTS

A total of 12 patients were ventilated mechanically under sedation with midazolam.

INTERVENTIONS

We monitored the consciousness level, heart rate, systemic blood pressure, pulmonary artery pressure, and pulmonary artery occlusion pressure before and after a bolus injection of 0.5 mg of flumazenil. The score for the consciousness level represents the sum of the scores for eye opening and best motor response, as determined by the Glasgow Coma Scale. We measured the cardiac output, concentrations of norepinephrine, epinephrine, and 3-methoxy-4-hydroxyphenylethyleneglycol in plasma, and concentration of cortisol in serum. We calculated the left ventricular ejection fraction, cardiac index, systemic vascular resistance index, pressure-rate product, systemic oxygen delivery, and systemic oxygen consumption at 0, 10, 30, and 60 mins after injection of flumazenil.

MEASUREMENTS AND MAIN RESULTS

The serum benzodiazepine's receptor binding activity in serum was in the range from 50 to 1000 ng/mL before injection of flumazenil. Flumazenil improved the consciousness level from 6.7+/-2.0 to 8.9+/-1.6 and induced transient elevations in heart rate, blood pressure, systolic pulmonary artery pressure, and pulmonary artery occlusion pressure. Left ventricular ejection fraction, oxygen delivery index, and pressure-rate product increased significantly, from 61%+/-8%, 640+/-170 mL/min/m2, and 13,300+/-2600 mm Hg/min at 0 mins to 67% +/-5%, 710+/-220 mL/min/m2, and 16,500+/-4400 mm Hg/min at 10 mins, respectively. Concentrations of norepinephrine and epinephrine in plasma increased significantly, from 890+/-840 pg/mL and 220+/-360 pg/mL, respectively, at 0 mins to 990+/-850 pg/mL and 270+/-300 pg/mL, respectively, at 10 mins. There were no significant changes in the plasma concentration of 3-methoxy-4-hydroxyphenylethyleneglycol, the serum concentration of cortisol after the administration of flumazenil.

CONCLUSIONS

Flumazenil did not result in a significant acute stress reaction in midazolam-sedated patients, but it increased myocardial oxygen consumption by enhancing sympathetic nervous activity or antagonizing cardiovascular depression induced by midazolam.

Massive noninflammatory periportal liver necrosis following concentrated acetic acid ingestion

In a fatal occurrence of massive liver necrosis following ingestion of concentrated (90%) acetic acid, the patient showed evidence of hemolysis, disseminated intravascular coagulation, and liver dysfunction at only 45 minutes after exposure. With refractory to vigorous supportive care, the patient s condition deteriorated until death occurred 39 hours after ingestion, despite some improvement of coagulopathy. Autopsy revealed corrosive injuries in the upper gastrointestinal tract and massive hepatic necrosis in a periportal distribution without significant inflammation. A direct effect of the noxious agent on hepatocytes involving the portal circulation is suggested.

Severe rhabdomyolysis following massive ingestion of oolong tea: caffeine intoxication with coexisting hyponatremia

A 36-y-o patient with schizophrenia, who had consumed gradually increasing quantities of oolong tea that eventually reached 15 L each day, became delirious and was admitted to a psychiatric hospital. After abstinence from oolong tea his delirium resolved. He was transferred to our hospital when he was discovered to have acute renal failure with hyponatremia (118 mEq/L) and severe rhabdomyolysis (creatine phosphokinase, 227,200 IU/L). On admission rhabdomyolysis had begun to improve despite a worsening of the hyponatremia (113 mEq/L). With aggressive supportive therapy, including hypertonic saline administration and hemodialysis, the patient fully recovered without detectable sequelae. The clinical course suggests that caffeine, which is present in oolong tea, was mainly responsible for the rhabdomyolysis as well as the delirium, although severe hyponatremia has been reported to cause rhabdomyolysis on rare occasions. We hypothesize that caffeine toxicity injured the muscle cells, which were fragile due to the potassium depletion induced by the coexisting hyponatremia, to result in unusually severe rhabdomyolysis. The possibility of severe rhabdomyolysis should be considered in a patient with water intoxication due to massive ingestion of caffeine-containing beverages.

A case of serious organophosphate poisoning treated by percutaneus cardiopulmonary support

We report a case of respiratory arrest, refractory circulatory collapse, and severe hypothermia following ingestion of an organophosphate insecticide. In addition to conventional management, including mechanical ventilation, administration of vasopressors, enteral lavage, charcoal hemoperfusion and administration of antidotes, extracorporeal cardiopulmonary support in the form of percutaneous cardiopulmonary support was successfully employed. Percutaneous cardiopulmonary support may be used for severe but potentially reversible pulmonary or cardiovascular toxicity induced by organophosphates as well as complicated severe hypothermia.

Rabbit syndrome following phenol ingestion

CASE REPORT

An elderly Japanese woman ingested a massive quantity of phenol in a suicide attempt. She was admitted to the Emergency Department in respiratory arrest and deep coma. Duodenogastritis was evident endoscopically. With the return of spontaneous respiration and consciousness, fine, rapid rhythmic perioral movements developed together with Parkinsonian findings. The abnormal movements were aggravated by administration of a neuroleptic and ameliorated by discontinuing the drug; they disappeared completely by hospital day 15. In addition to neuroleptic drugs, phenol intoxication may cause the rabbit syndrome by inducing cholinergic dominance with relative dopamine hypofunction in the central nervous system.

Effect of charcoal hemoperfusion on clearance of cibenzoline succinate (cifenline) poisoning

BACKGROUND

Management of cibenzoline succinate (cifenline) poisoning by symptomatic treatment is recommended because it has been reported cibenzoline succinate is not effectively removed by hemodialysis. The use of charcoal hemoperfusion for patients with cibenzoline succinate poisoning has not been reported previously.

CASE REPORT

An 80-year-old woman with permanent right ventricular pacing was admitted to our hospital with general fatigue and clouding of consciousness. She had been receiving cibenzoline succinate for 1 month. The patient was clearly in shock on admission. Electrocardiogram showed a prolonged QRS and QTc interval and pacing failure. Hemodynamic failure, electrocardiographic abnormalities including pacing failure, and liver and renal dysfunction were compatible with cibenzoline succinate poisoning. Symptomatic treatment was provided. On day 4, charcoal hemoperfusion was initiated because of the development of hypoglycemia accompanied by liver and renal dysfunction. After charcoal hemoperfusion, the hypoglycemia, liver and renal dysfunction, prolonged QRS and QTc interval, and pacing threshold resolved. She was discharged on digoxin. We present a case of cibenzoline succinate poisoning treated with charcoal hemoperfusion which resulted in a rapid reduction of cibenzoline plasma concentrations with a significant clinical improvement.

[Progress in interventional radiology (IVR) in emergency medicine]

IVR has attracted much attention in Japan over the past decade, and it is expected to be rapidly developed and widely used. Not surprisingly, IVR has already become essential in emergency medicine. This paper addresses IVR of the thoracic and abdominal areas and the pelvis in emergency medicine, in particular the recent IVR focus on the vasculature. CO2-DSA, which enables extravasation and easy detection of a arteriovenous or portal shunt, is also useful in the detection of bleeding in emergency situations. In trauma cases, TAE, originating from an expanded concept of "damage control," is commonly used to stop bleeding in order to perform surgical treatment or used during surgery. Occasionally the two applications are combined when appropriate. TAE is effective in controlling retroperitoneal bleeding resulting from pelvic fracture and parenchymatous organ injuries in the abdominal area. Treatment with stent-grafts, originally used to treat true aneurysms, has recently been used for treatment of injuries of the aorta or arteries and for entry closure due to aortic dissection. Furthermore, stent placement is expected to become an effective cure for organ ischemia, resulting from acute dissections. Is addition, in order to cure rupture of esophagus or gastric varices, such new treatments as TIPS and BRTO have increasingly been used, coupled with the conventional PTO treatment. Continuous regional arterial infusion of protease inhibitor, in an attempt to cure severe acute pancreatitis, significantly reduced the infectious rate at the necrotic lesion, and its resulting mortality rate. It is certain that great progress has been made in emergency medicine. We also should realize that it is desirable to be well versed even in new IVR.

The factors influencing haematoma volume due to arteriovenous malformations

Haemorrhage due to cerebral arteriovenous malformations (AVMs) varies from massive, requiring urgent operations, to clinically silent. The present study was designated to identify factors influencing haematoma size, and the pathophysiological mechanisms of massive haemorrhage were studied. 55 patients with intracerebral haematomas due to supratentorial AVMs were included in this study. Angiographic and clinical findings were retrospectively evaluated in relation to haematoma size. Statistical analysis demonstrated that small size and the presence of only one draining vein were high risk factors for massive haemorrhage. The haematoma volume in small AVMs (30 +/- 4 cm3) was significantly larger than in other AVMs (7 +/- 3 cm3) (p = 0.0005). AVMs with only one draining vein were associated with massive haematoma volume as compared to AVMs with two or more draining veins (30 +/- 4 versus 11 +/- 3 cm3, p = 0.0023). Our previous study demonstrated that feeding artery pressure (FAP) was significantly higher in AVMs with haemorrhage than in those without, as was draining vein pressure (DVP), and FAP and DVP were inversely related to the number of draining veins and the size of the AVMs. Thus, in small AVMs and AVMs with only one draining vein, local increase in DVP may thus contribute to massive haemorrhage.

Interobserver and intraobserver variation in endoscopic assessment of GERD using the "Los Angeles" classification

BACKGROUND

A new endoscopic classification of gastroesophageal reflux disease (GERD) has been proposed, and the term mucosal break has been introduced to describe mucosal damage. This new classification was evaluated by endoscopists with different levels of experience.

METHODS

Fifty endoscopic photographs for each of 20 randomly selected patients with GERD were assessed retrospectively by three groups of seven endoscopists classified by experience: group 1 (100 to 500 procedures), group 2 (500 to 3000), and group 3 (more than 3000). The new classification was modified by adding grade 0 to describe healed mucosal breaks, so that there were five grades. All photographs were assessed twice at an interval of more than 1 week, and kappa statistics were used to determine observer variation.

RESULTS

Interobserver variation within group 3 (kappa = 0.39, n = 21) and between groups 3 and 2 (kappa = 0.36, n = 49) was significantly different (p < 0.01) from that between groups 3 and 1 (kappa = 0.26, n = 49). Intraobserver variation in group 1 (kappa = 0.39, n = 7) was significantly different (p < 0.01) from that in group 2 (kappa = 0.51, n = 7) and group 3 (kappa = 0.54, n = 7).

CONCLUSIONS

Observer variation depends on level of endoscopic experience. Only experienced endoscopists should use the new classification for grading of GERD.

Granulocyte-macrophage colony-stimulating factor prevents the progression of atherosclerosis via changes in the cellular and extracellular composition of atherosclerotic lesions in watanabe heritable hyperlipidemic rabbits

BACKGROUND

A cytokine network is involved in atherogenesis. This study was conducted to investigate the effects of granulocyte-macrophage colony-stimulating factor (GM-CSF) on the development and composition of atherosclerotic lesions in Watanabe heritable hyperlipidemic (WHHL) rabbits.

METHODS AND RESULTS

GM-CSF (10 microg. kg-1. d-1) was administered to 4-month-old WHHL rabbits (n=9) 5 days a week for 7.5 months, whereas an equal dose of human serum albumin was administered to controls (n=9). The cholesterol levels were not changed significantly by the treatment. Age-matched 4-month-old rabbits (n=7) had atheromatous plaques over 30.7+/-5.7% of the inner surface area of the aortic arch. After treatment, the percentages of surface atheromatous plaques to total aortic arch area were 45.0+/-12.6% in the GM-CSF group and 74.3+/-11.0% in controls (P<0.0001). Histological examination demonstrated that GM-CSF reduced the ratio of intima to media (P<0.01) and cross-sectional areas of atherosclerotic lesions (P<0.0001). Quantitative analysis indicated a marked decrease in the areas of smooth muscle cells (P=0.0001), collagen (P=0.0001), and extracellular lipid deposits (P<0.05) of atheromatous plaques in GM-CSF-treated rabbits compared with controls. The terminal deoxynucleotidyltransferase-mediated dUTP-digoxigenin nick end-labeling (TUNEL) method and immunohistochemistry were performed to examine the relationship between decreased atherosclerotic lesions and apoptosis. The percentage of TUNEL-positive cells increased in the GM-CSF group (GM-CSF, 24.1+/-4.4% versus control, 11.6+/-3.2%; P<0.0001). GM-CSF enhanced the apoptosis of smooth muscle cells in the shoulder region and the fibrous cap (P<0.0001), suggesting one of the mechanisms for the antiatherogenic effect.

CONCLUSIONS

GM-CSF altered the composition of atherosclerotic lesions and reduced the atherosclerosis in WHHL rabbits.

Association of head trauma with cervical spine injury, spinal cord injury, or both

BACKGROUND

Links between cervical spine and/or spinal cord injuries and head trauma have not been reported in detail.

METHODS

188 patients with cervical spine and/or spinal cord injury were divided into two groups, i.e., with upper cervical and mid-lower cervical injury, and compared for head injury.

RESULTS

Associated head trauma was investigated in 188 patients with cervical spine and/or spinal cord injuries; 35% had moderate or severe injuries. Brain damage was more frequently observed in patients with upper cervical injury than in those with mid to lower cervical injury. Those patients with upper cervical injury appeared to have an elevated risk of suffering skull base fractures, traumatic subarachnoid hemorrhage, and contusional hemotoma.

CONCLUSIONS

Approximately one third of patients with cervical spine and/or spinal cord injuries had moderate or severe head injuries. Brain damage was more frequently associated with upper cervical injury. Those patients with upper cervical injury are at greater risk of suffering from skull base fractures and severe intracranial hematomas than those with mid to lower cervical injury.

Susceptibility to hydrogen peroxide and catalase activity of root nodule bacteria

The root nodule bacteria (free-living cells) tested had higher susceptibility to hydrogen peroxide (H2O2) than the other genera of aerobic or facultative anaerobic bacteria tested. The catalase activities tended to have a positive correlation with H2O2 resistance among all bacteria tested. Addition of a catalase inhibitor such as 3-amino-1, 2, 4-triazole increased the susceptibility to H2O2. These results suggest that the lower catalase activity brings about the higher susceptibility of root nodule bacteria to H2O2. Root nodule bacteria seemed to have two or three catalase isozymes during growth and their catalase activities were higher in log phase than in stationary phase, contrary to other genera of bacteria tested.

Hypokalemia with syncope caused by habitual drinking of oolong tea

A 61-year-old woman developed hypokalemia, atrioventricular block and ventricular tachycardia with syncope after habitual drinking 2 to 3 liters of oolong tea per day. She had been suffering from rheumatoid arthritis and Sjögren's syndrome and her serum albumin was decreased (2.9 g/dl). Oolong tea contains caffeine at approximately 20 mg/dl. Great quantities of caffeine can induce hypokalemia. The serum protein binding caffeine is albumin. Accordingly, in patients with hypoalbuminemia, caffeine is apt to induce hypokalemia. This case suggested that great quantities of oolong tea, one of the so-called "healthy" drinks, result in serious symptoms for patients with hypoalbuminemia.